Anesth Analg
· 2026 Jul · PMID 42307929
·
Full text
BACKGROUND: Previous observational studies demonstrated a significant association between allogeneic red blood cell (RBC) transfusion and an increased risk of postoperative venous thromboembolism (VTE). However, the conf...BACKGROUND: Previous observational studies demonstrated a significant association between allogeneic red blood cell (RBC) transfusion and an increased risk of postoperative venous thromboembolism (VTE). However, the confounding effects of procoagulant agent administration have seldom been addressed. METHODS: This retrospective cohort study included patient who underwent major surgery between 2018 and 2022 at a general referral university-affiliated hospital located in Beijing, China. The exposure was the transfusion of allogeneic RBC products from the surgery day through 30 days postoperatively. The primary outcome was postoperative in-hospital VTE, diagnosed by venous ultrasound or computed tomography pulmonary angiography. Up to 37 patient- or treatment-related confounders, including anemia, estimated blood loss, fresh frozen plasma (FFP) transfusion, were adjusted for using multivariable logistic regression models and the propensity score overlap weighting. RESULTS: Among the 83,478 patients included, 8372 patients (10.0%) received perioperative RBC transfusion, while postoperative VTE occurred in 905 patients (1.1%). Among patients who received RBC transfusions, 75.9% also received FFP. In the unadjusted analysis, RBC transfusion was significantly associated with VTE (odds ratio [OR] = 5.09; 95% confidence interval [CI], 4.43-5.84; P < .001). However, this association was no longer significant after adjusting for all confounders using logistic regression (OR = 1.02; 95% CI, 0.78-1.33; P = .893) or the propensity score overlap weighting (OR = 1.02; 95% CI, 0.77-1.35; P = .874). FFP transfusion was associated with a higher risk of postoperative VTE (OR = 1.33; 95% CI, 1.10-1.62; P = .004). The effect of RBC transfusion on VTE was not modified by FFP transfusion (P for interaction = .612), and remained nonsignificant in either subgroup of patients receiving or not receiving FFP transfusion. CONCLUSIONS: After adjustment for confounders, perioperative RBC transfusion was not associated with an increased risk of postoperative VTE, whereas FFP transfusion showed a significant association with VTE.
BACKGROUND: Postoperative delirium is the most common postsurgical complication in older adults and is associated with an increased risk of long-term cognitive decline and Alzheimer's disease (AD) and related dementias (...BACKGROUND: Postoperative delirium is the most common postsurgical complication in older adults and is associated with an increased risk of long-term cognitive decline and Alzheimer's disease (AD) and related dementias (ADRD). However, the neurological basis of this increased risk-whether postoperative delirium unmasks latent preoperative pathology or leads to AD-relevant pathology after perioperative brain injury-remains unclear. METHODS: To investigate potential brain microstructural abnormalities associated with postoperative delirium and cognitive function, we analyzed pre- and post-operative Neurite Orientation Dispersion and Density Imaging (NODDI) MRI data within the posterior cingulate cortex (PCC) from 110 patients aged ≥60 years who underwent non-cardiac/non-intracranial surgery. RESULTS: We found increased free water (FISO) and decreased neurite density index (NDI) and orientation dispersion index (ODI) in the dorsal PCC before surgery among those who later developed postoperative delirium (n = 12) versus those who did not (n = 98). Preoperative dorsal PCC NDI and ODI values were also positively associated with preoperative attention/concentration performance, independent of age, education level, and global brain atrophy (NDI: = 0.29 (95% CI, 0.10-0.50), P = .008; ODI: = 0.29 (95% CI, 0.03-0.44), P = .004). Yet, these diffusion metrics were not correlated with cerebrospinal fluid amyloid beta (Aβ) positivity or levels. CONCLUSIONS: These results suggest that preoperative latent brain abnormalities within the dorsal PCC may underlie attention/concentration deficits and susceptibility to postoperative delirium, yet these dorsal PCC NODDI abnormalities were not significantly associated with CSF Aβ levels (a measure of brain Amyloid deposition). Our findings highlight microstructural vulnerability within the PCC, a key region of the default mode network, as a neuroanatomic locus that can help explain the link between preoperative attention/concentration deficits and increased postoperative delirium risk among vulnerable older surgical patients.
BACKGROUND: Patients with anemia preparing for abdominal cancer surgery in whom transfusion is not an option require careful preoperative management. Cancer-related anemia is often multifactorial. Therefore, we applied a...BACKGROUND: Patients with anemia preparing for abdominal cancer surgery in whom transfusion is not an option require careful preoperative management. Cancer-related anemia is often multifactorial. Therefore, we applied a blood augmentation protocol based on patient blood management (PBM), which optimizes the patient's own red cell mass. We aimed to evaluate the effect of this protocol on surgical outcomes in patients with gastrointestinal and hepato-biliary-pancreatic cancers requiring transfusion-free surgery by comparing outcomes between patients with and without preoperative anemia (the anemic and non-anemic groups). All participants were Jehovah's Witnesses for whom transfusion was not an option. METHODS: We retrospectively analyzed consecutive Jehovah's Witness patients admitted to Shonan Atsugi Hospital between January 2017 and December 2020. Patients with preoperative anemia underwent a blood augmentation protocol from their first visit until surgery. They received iron and vitamin supplementation (folic acid, vitamin C, B12, and B6), and an erythropoiesis-stimulating agent. The primary outcomes were 30-day postoperative mortality and complications (Clavien-Dindo grade >IIIa). The secondary outcomes included waiting time to surgery and perioperative hemoglobin (Hb) values measured at protocol initiation, 1 to 3 days before surgery, and postoperative days (PODs) 1, 3, and 7. RESULTS: Of the 125 registered cases, 100 patients were analyzed (44 patients in the anemic group receiving blood augmentation (mean ± standard deviation [SD] age 70.9 ± 7.8 years; 26 [59.1%] female); 56 patients in the nonanemic group (age 66.4 ± 10.4 years; 35 [62.5%] female). The 30-day mortality rate (0/44 [0%] vs 0/56 [0%]) and the incidence of severe complications (9/44 [20.6%] vs 11/56 [19.6%]) did not differ between the two groups. Age-adjusted logistic regression for complications confirmed no significant difference (unadjusted odds ratio [OR] = 1.05; 95% confidence interval [CI], 0.39-2.82, P =.92 and age-adjusted OR = 0.94; 95% CI, 0.34-2.64, P =.91). The waiting time to surgery-which corresponds to the blood augmentation period for the anemic group-did not differ significantly (median 27 [interquartile range {IQR}, 15-39] vs 20 [IQR, 13-27] days, P =.13). In the anemic group, Hb improved from 10.8 ± 2.0 at baseline to 11.5 ± 1.2 g/dL preoperatively and then postoperatively recovered to levels comparable to those of the non-anemic group by POD 7 (10.5 ± 1.8 vs 10.9 ± 1.6 g/dL). Perioperative Hb levels showed significant time-by-intervention interactions (F4,368 = 13.9; P <.001). CONCLUSIONS: Proactive blood augmentation in patients with preoperative anemia enables safe and effective transfusion-free cancer surgery without delaying the indicated procedure. Multidisciplinary PBM approaches incorporating blood augmentation yielded short-term outcomes comparable to those of patients without preoperative anemia.
BACKGROUND: Older adults undergoing surgery frequently experience postoperative delirium and postoperative neurocognitive disorders (NCD), but the neuropathophysiology of these conditions remains obscure. A postoperative...BACKGROUND: Older adults undergoing surgery frequently experience postoperative delirium and postoperative neurocognitive disorders (NCD), but the neuropathophysiology of these conditions remains obscure. A postoperative inflammatory cascade with subsequent neuronal injury is one theory that requires further investigation. We report the incidence of delirium and postoperative NCD using updated nomenclature and investigate changes in inflammatory and neuronal injury biomarkers associated with these conditions. METHODS: We performed a prospective, longitudinal, cohort study with older adults aged 60 years or more undergoing major elective noncardiac surgery. Patients completed cognitive assessments preoperatively and at 3 and 28 months postoperatively, alongside twice-daily delirium assessments during hospital admission. Plasma was obtained before surgical incision and at 30 minutes, 6, 24, and 48 hours postoperatively and assayed for cytokines (interleukin [IL]-6, IL-10, IL-18, tumor necrosis factor [TNF]α) and neuronal injury markers (neurofilament light [NfL], total Tau, and pTau181). RESULTS: We enrolled 79 patients (mean age: 69 [standard deviation {SD}: 6.5]; female: 45.6%). Thirteen patients (15.2%) experienced postoperative delirium. At 3 months, 18 of 63 (28.6%) had postoperative NCD, and at long-term follow-up, 17 of 46 (37.0%) had NCD. IL-6, IL-10, total Tau, p-Tau181, and NfL levels were 10.3, 1.9, 1.3, 1.2, and 1.6 times higher at 48 hours postsurgery compared to baseline (all P <.05). IL-18 levels were 1.1 times lower. TNFα remained unchanged. Linear mixed-effects models revealed that greater elevations in IL-6 levels were associated with increased delirium risk (β = 22.23, standard error {SE} = 9.48, P =.02) and long-term NCD (β = 12.46, SE = 6.02, P =.04). CONCLUSIONS: Using updated nomenclature, postoperative delirium and postoperative NCD affect a third of surgical patients and inflammatory and neuronal injury markers are elevated after surgical intervention. Increases in IL-6 and pTau181 at the time of surgery are associated with postoperative delirium; increases in IL-6 are also associated with long-term NCD. Specific biomarkers follow unique time courses after anesthesia and surgery.
BACKGROUND: Remimazolam, a novel short-acting benzodiazepine, is associated with more stable intraoperative hemodynamics than propofol. Older adults undergoing hip fracture surgery represent a vulnerable population at el...BACKGROUND: Remimazolam, a novel short-acting benzodiazepine, is associated with more stable intraoperative hemodynamics than propofol. Older adults undergoing hip fracture surgery represent a vulnerable population at elevated risk for perioperative cardiovascular complications. However, whether remimazolam's hemodynamic advantages translate into reduced major adverse cardiovascular events (MACE) in this population remains uncertain, particularly given recent randomized trials questioning the relationship between intraoperative blood pressure management and postoperative outcomes. We aimed to compare 30-day in-hospital MACE and all-cause in-hospital mortality after general anesthesia with remimazolam versus propofol. METHODS: We conducted a retrospective cohort study using a target trial emulation framework with data from a multicenter Japanese hospital administrative database (September 1, 2020, to September 30, 2024). Eligible participants were adults aged 65 to 99 years undergoing hip fracture surgery who received total intravenous anesthesia with remimazolam or propofol on the day of surgery. The primary outcome was 30-day in-hospital MACE, and the secondary outcome was 30-day all-cause in-hospital mortality. We estimated the average treatment effect among patients who received remimazolam compared with propofol using propensity score weighting. Risks and 95% confidence intervals (CIs) were obtained from weighted cumulative incidence functions with bootstrap resampling. RESULTS: Of 132,422 patients identified, 14,027 were included in the analysis. The primary outcome occurred in 2.86% of the remimazolam group and 2.74% of the propofol group, with no meaningful difference between groups (risk ratio, 1.04 [95% CI, 0.80-1.38]; P = 0.76; risk difference, 0.12% [95% CI, -0.64% to 0.90%]). Thirty-day all-cause in-hospital mortality also did not differ materially between groups (risk ratio, 1.03 [95% CI, 0.61-1.80]; P = 0.91). These findings remained consistent across sensitivity analyses and in subgroup analyses stratified by baseline cardiovascular risk. CONCLUSIONS: Among older adults undergoing hip fracture surgery, 30-day in-hospital MACE and mortality did not differ substantially between remimazolam and propofol, suggesting that anesthetic selection between these agents may not substantially affect short-term cardiovascular outcomes in this high-risk population.
BACKGROUND: Prehabilitation during unavoidable surgical delay after an acute femoral neck fracture may mitigate rapid functional decline but is often limited by movement-evoked pain. The pericapsular nerve group (PENG) b...BACKGROUND: Prehabilitation during unavoidable surgical delay after an acute femoral neck fracture may mitigate rapid functional decline but is often limited by movement-evoked pain. The pericapsular nerve group (PENG) block is a motor-sparing regional anesthetic technique that may facilitate active mobilization. We hypothesized that the PENG block would improve completion of a structured prehabilitation session. METHODS: In this single-center, randomized, double-blind, placebo-controlled trial, adults with Garden III to IV femoral neck fractures awaiting hip arthroplasty received ultrasound-guided PENG block with 20 mL 0.375% ropivacaine or saline before initial prehabilitation. The primary outcome was completion of all five predefined mobilization steps. Secondary outcomes included pain during prehabilitation, rescue analgesia within 24 hours, postoperative Cumulated Ambulation Score (postoperative days 1-3), Barthel Index at discharge, length of stay, discharge disposition, and adverse events. Analyses followed the intention-to-treat principle. RESULTS: We randomized 100 patients (50 PENG; 50 placebo). Completion of the full prehabilitation session did not differ between groups (22 of 50 [44%] vs 24 of 50 [48%], P =.841). Maximum movement pain was lower with PENG block (median [interquartile range], 7 [5-8.75] vs 8 [7-10], P =.022), and fewer patients required rescue analgesia (2 of 50 [4%] vs 10 of 50 [20%], P=.028). We did not observe between-group differences in postoperative outcomes. No block-related or prehabilitation-related adverse events occurred. CONCLUSIONS: PENG block administered before the initial prehabilitation was associated with reduced movement-related pain and rescue analgesic use but did not improve the initial prehabilitation completion or postoperative functional recovery. More effective multimodal analgesic strategies may be required to enable active prehabilitation.